Childbirth: What is an episiotomy?

An episiotomy is a 2.5–5 cm incision (cut) that is made in the lower vagina to widen the vaginal opening and facilitate the passage of the baby during childbirth.

If the mother hasn’t already been given an epidural, the doctor will first inject a local anesthetic into the perineal area to minimize discomfort. If the mother has received an epidural, the doctor will make sure that the anesthetic has sufficiently numbed the perineum. After delivery, stitches are used to close the incision.

Why perform an episiotomy?

To date, no studies have shown that performing an episiotomy without medical indication has any benefits. According to the Society of Obstetricians and Gynaecologists of Canada (SOGC), an episiotomy should therefore be performed only when necessary.

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That said, there are few situations where an episiotomy is recommended. This may be the case if it is the mother’s first pregnancy and forceps must be used during delivery to prevent third- or fourth-degree tearing. An episiotomy may also be considered if the mother or infant is in distress, making it necessary to deliver the baby’s head quickly, but one of the perineal muscles is blocking its passage.

Episiotomy has the following disadvantages:

• Pain and swelling at the incision site
• Risk of infection
• Risk of increased blood loss
• Increased risk of deep tears in the perineum (in certain situations)
• Low risk of pain during vaginal intercourse over the long term

The side effects of an episiotomy can also vary depending on the type of incision.

Talk to your doctor before delivery to discuss when an episiotomy might be performed.

Is it possible to prevent perineal tearing?

There are 4 types of perineal tears, which are categorized by severity. A first-degree tear is a skin-deep injury near the vaginal opening, whereas a fourth-degree tear extends to the rectum.

First- and second-degree tears are the most common, especially among women who are giving birth vaginally for the first time. Fourth-degree perineal tears occur in about 1 percent of deliveries and are often associated with the use of forceps or vacuum devices. They can also arise during a delivery where the baby is in a posterior position or weighs more than 4 kg.

There are several simple ways to reduce the risk of perineal tearing:

• Push while lying on your side.
• Apply a warm compress to the perineum and apply supporting pressure when the baby’s head presses against it during childbirth to control tearing as much as possible (this procedure is performed by the medical team).
• Conduct a prenatal perineal assessment with the help of a physiotherapist specializing in perineal rehabilitation. This will not prevent tearing entirely, but may reduce the severity of any tears. Preparing the perineum can also promote healing and recovery after childbirth.

Is perineal massage effective in preventing the need for episiotomy?

Perineal massage consists in manually stretching the vaginal muscles. It is believed to improve the elasticity of the perineal tissues by increasing blood flow to the area. Studies show that massaging the perineum 4–6 weeks prior to delivery may help prevent injuries requiring stitches and lower the risk of needing an episiotomy. However, the benefits appear to be minimal and limited to women who are having their first child.

You can perform this massage yourself or enlist the help of your partner. Simply put a lubricant on your fingers, then gently insert them into your vagina. Gently massage your vagina by applying downward pressure in a U movement. Some experts suggest practising perineal massage daily starting from the 36th week of pregnancy, while others believe that doing so once or twice in the week before delivery is sufficient.

Perineal massage can also be performed during childbirth. In fact, some studies have shown a decrease in third- and fourth-degree perineal tears when perineal massage is done during the second stage of labour. Perineal massage during delivery has also been associated with less pain after childbirth and faster recovery.

Things to keep in mind

• An episiotomy is an incision made at the bottom of the vagina to facilitate the passage of the baby.
• Episiotomy should be performed for medical reasons only.
• Certain measures can reduce the risk of perineal tears.

Scientific review: Roxanne Piché, nursing adviser, Maternal Fetal Medicine Clinic, CHU Sainte-Justine Research and copywriting:The Naître et grandir team Updated: July 2021

Photo: iStock/naphtalina